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Background Over time, NIH funding has become increasingly competitive. In addition, academic surgeons’ research competes with time required for patient care, operating, and administrative work. Due to these competing interests for surgeons, we hypothesize that the percentage of NIH grants awarded to researchers from departments of surgery is decreasing. Methods The NIH Research Portfolio Online Reporting Tool was queried for the number and value of new and renewal R01 grants, and career development awards noting which surgery departments received awards from 1998 to -2018. Statistical analysis was performed using univariate and multivariable logistic regression. Results The number of career development awards granted to researchers from departments of surgery decreased significantly over time (P = 0.007) while new R01’s and R01 renewal awards were stable. The number of grants awarded to researchers from all procedural departments were compared to non-procedural departments and again, career development awards decreased significantly (P = 0.005) over time but new R01’s and R01 renewals stayed stable. Looking at the difference in average dollar amount received for new R01, renewal R01, or career development awards between department of surgery awardees and non-surgery over time, there was no significant difference. Conclusions NIH funding is becoming increasingly competitive and surgeons have many competing interests. Our study found that there has been a significant decrease in career development awards to department of surgery awardees and procedural specialists. The decrease in receipt of these awards is particularly concerning given that they are meant to provide protected time for developing researchers and thus have potential consequences for future research.

Background Informed consent forms consist of large blocks of written information that may be difficult for patients to understand. Visual teaching aids are promising, however, they have not been studied as a pre-operative educational tool for common surgical procedures. We pilot tested the use of a visual teaching aid during the informed consent process for a colectomy. Methods A randomized pilot study was performed. Participants were randomized into the visual teaching aid group or standard care. Following the consent process, participants were questioned about potential surgical complications, anxiety, satisfaction, and understanding. Results 30 participants were enrolled. Potential complication recall and patient-reported understanding were improved in the visual group (p = 0.01, p = 0.03). Anxiety levels were reduced in the visual group (p = 0.02). No statistically significant data were found for satisfaction (p = 0.75). Conclusions Utilizing a visual teaching aid during the consent process for colectomy increases patient recall of risks, reduces anxiety, and improves understanding.

Background: Quality of life and psychosocial determinants of health, such as health literacy and social support, are associated with increased health care utilization and adverse outcomes in medical populations. However, the effect on surgical health care utilization is less understood. Objective: We sought to examine the effect of patient-reported quality of life and psychosocial determinants of health on unplanned hospital readmissions in a surgical population. Research Design: This is a prospective cohort study using patient interviews at the time of hospital discharge from a Veterans Affairs hospital. Subjects: We include Veterans undergoing elective inpatient general, vascular, or thoracic surgery (August 1, 2015–June 30, 2017). Measures: We assessed unplanned readmission to any medical facility within 30 days of hospital discharge. Results: A total of 736 patients completed the 30-day postoperative follow-up, and 16.3% experienced readmission. Lower patient-reported physical and mental health, inadequate health literacy, and discharge home with help after surgery or to a skilled nursing or rehabilitation facility were associated with an increased incidence of readmission. Classification regression identified the patient-reported Veterans Short Form 12 (SF12) Mental Component Score

Health literacy (HL) impacts medical care. We hypothesized that patients with low HL would have higher readmission rates following surgery.We conducted a prospective, multi-institutional study from 8/2015-6/2017 within the Veterans Affairs (VA) System including veterans who underwent general, vascular, or thoracic surgery. HL was assessed by Brief Health Literacy Screener and stratified into adequate vs. low. Patients were followed for 30 days post-discharge. Multivariable analyses examined correlations and logistic regression models adjusted for covariates.736 patients were enrolled in the study; 98% (n = 722) completed the HL survey. At discharge, 33.2% of patients had low HL. The overall 30-day readmission rate was 16.3%, with a significant difference by HL (Adequate HL: 13.3% vs. Low HL: 22.5%, p 0.01). After adjusting for clinical and demographic covariates, patients with low HL were 59% more likely to be readmitted (OR = 1.59, 95% CI = 1.02-2.50).Low HL is common among VA surgery patients and is associated with readmission. Future studies should be focused on interventions to target this vulnerable patient population.

Patient education materials (PEMs) serve as a foundation for educating patients and families across all surgical fields but are often not understandable. The National Institute of Health (NIH) recommends that PEMs be written at a grade 6-7 reading level; however, most current materials exceed that measure.

Understanding variation in perioperative opioid exposure and its effect on patients' outcomes is critical for pain management. This study characterized perioperative exposure to morphine and its association with postoperative pain and 30-day readmissions. We utilized nationwide Veterans Healthcare Administration (VHA) data on four high-volume surgical procedures, 2007-2014. We identified 235,239 Veterans undergoing orthopedic, general, or vascular surgery; 5.4% high trajectories (116.1 OME/Day), 53.2% medium trajectories (39.7 OME/Day), and 41.4% low trajectories (19.1 OME/Day). Modeled estimates suggest that patients in the high OME group had higher risk of a pain-related readmission (OR: 1.59; CI: 1.39, 1.83) compared to the low OME trajectory. Yet when stratified by pain trajectory, patients with high pain and high OME had lower risk of a pain-related readmission compared to patients in the high pain low OME group (OR: 0.76, CI: 0.62, 0.94). In conclusion, patients receiving high perioperative OME are more likely to return to care for pain-related problems. This study highlights opportunities to reduce the amount of prescriptions opioids in the communities.

Background Postoperative urinary retention (POUR) and catheter-associated urinary tract infections (CAUTI) are associated with significantly longer hospital length-of-stay and increased costs.1 This study investigates the effect of early removal of urinary catheters on POUR and CAUTI in patients undergoing an ERP with a preoperative intrathecal injection. Methods Retrospective cohort study of a prospectively maintained database of patients who underwent elective colorectal surgery in an Enhanced Recovery pathway was compared to historical National Surgical Quality Improvement Program cohort of patients. Primary outcomes measured are 30-day POUR and postoperative CAUTI rates. Results The overall POUR rate of ERP patients compared to non-ERP patients was significantly less (8% vs. 13%, p Conclusions For patients undergoing ERP with a preoperative intrathecal opioid injection, early removal of urinary catheter significantly decreased POUR and did not significantly affect CAUTI rates. Summary The effect of early removal of urinary catheters on postoperative urinary retention and catheter-associated UTI rates in patients undergoing an ERP with a single preoperative intrathecal opioid injection was studied. Early urinary catheter removal after intrathecal injection was associated with decreased rates of POUR and equivalent CAUTI rates.

Background Despite high risk for cardiovascular disease (CVD) mortality, screening and treatment of hyperlipidemia in patients with rheumatoid arthritis (RA) is suboptimal. We asked primary care physicians (PCPs) and rheumatologists to identify barriers to screening and treatment for hyperlipidemia among patients with RA. Methods We recruited rheumatologists and PCPs nationally to participate in separate moderated structured group teleconference discussions using the nominal group technique. Participants in each group generated lists of barriers to screening and treatment for hyperlipidemia in patients with RA, then each selected the three most important barriers from this list. The resulting barriers were organized into physician-, patient- and system-level barriers, informed by the socioecological framework. Results Twenty-seven rheumatologists participated in a total of 3 groups (group size ranged from 7 to 11) and twenty PCPs participated in a total of 3 groups (group size ranged from 4 to 9). Rheumatologists prioritized physician level barriers (e.g. ‘ownership’ of hyperlipidemia screening and treatment), whereas PCPs prioritized patient-level barriers (e.g. complexity of RA and its treatments). Conclusion Rheumatologists were conflicted about whether treatment of CVD risk among patients with RA should fall within the role of the rheumatologist or the PCP. All participating PCPs agreed that CVD risk reduction was within their role. Factors that influenced PCPs’ decisions for screening and treatment for CVD risk in patients with RA were mainly related to their concern about how treatment for CVD risk could influence RA symptomatology (myalgia from statins) or how inflammation from RA and RA medications influences lipid profiles.

BACKGROUND Acute kidney injury is associated with increased postoperative length of hospital stay and increases the risk of postoperative mortality. The association between the development of postoperative acute kidney injury and the implementation of an enhanced recovery after surgery protocol remains unclear. OBJECTIVE This study aimed to examine the relationship between the implementation of an enhanced recovery pathway and the development of postoperative acute kidney injury. DESIGN In this retrospective cohort study, a prospectively maintained database of patients who underwent elective colorectal surgery in an enhanced recovery pathway were compared to a hospital historical National Surgical Quality Improvement Program colorectal registry of patients. SETTINGS This study was conducted at the University of Alabama at Birmingham, a tertiary referral center. PATIENTS A total of 1052 patients undergoing elective colorectal surgery from 2012 through 2016 were included. MAIN OUTCOME MEASURES The development of postoperative acute kidney injury was the primary outcome measured. RESULTS Patients undergoing an enhanced recovery pathway had significantly greater rates of postoperative acute kidney injury than patients not undergoing an enhanced recovery pathway (13.64% vs 7.08%; p < 0.01). Our adjusted model indicated that patients who underwent an enhanced recovery pathway (OR, 2.31; 95% CI, 1.48-3.59; p < 0.01) had an increased risk of acute kidney injury. Patients who developed acute kidney injury in the enhanced recovery cohort had a significantly longer median length of stay than those who did not (median 4 (interquartile range, 4-9) vs 3 (interquartile range, 2-5) days; p=0.04). LIMITATIONS This study did not utilize urine output as a modality for detecting acute kidney injury. Data are limited to a sample of patients from a large academic medical center participating in the National Surgical Quality Improvement Program. Interventions or programs in place at our institution that aimed at infection reduction or other initiatives with the goal of improving quality were not accounted for in this study. CONCLUSION The implementation of an enhanced recovery after surgery protocol is independently associated with the development of postoperative acute kidney injury.See Video Abstract at http://links.lww.com/DCR/B69. LA ASOCIACION DE VIA DE RECUPERACION MEJORADA Y LESION RENAL AGUDA EN PACIENTES DE CIRUGIA COLORRECTAL: La lesion renal aguda se asocia con una mayor duracion en la estancia hospitalaria y aumenta el riesgo de la mortalidad postoperatoria. La asociacion entre el desarrollo de la lesion renal aguda postoperatoria y la implementacion de un protocolo de Recuperacion Mejorada despues de la cirugia, sigue sin ser clara.Examinar la relacion entre la implementacion de una via de Recuperacion Mejorada y el desarrollo de lesion renal aguda postoperatoria.Estudio de cohorte retrospectivo, de una base de datos mantenida prospectivamente, de pacientes que se sometieron a cirugia colorrectal electiva, en una via de Recuperacion Mejorada, se comparo con el registro historico de los pacientes colorrectales del Programa Nacional de Mejora de la Calidad Quirurgica.Universidad de Alabama en Birmingham, un centro de referencia terciario.Un total de 1052 pacientes sometidos a cirugia colorrectal electiva desde 2012 hasta 2016.Desarrollo de lesion renal aguda postoperatoria.Los pacientes sometidos a una via de Recuperacion Mejorada, tuvieron tasas significativamente mayores de lesiones renales agudas postoperatorias, en comparacion con los pacientes de Recuperacion no Mejorada (13.64% vs 7.08%; p < 0.01). Nuestro modelo ajustado indico que los pacientes que se sometieron a una via de Recuperacion Mejorada (OR, 2.31; IC, 1.48-3.59; p < 0.01) tuvieron un mayor riesgo de lesion renal aguda. Los pacientes que desarrollaron dano renal agudo en la cohorte de Recuperacion Mejorada, tuvieron una estadia mediana significativamente mas larga en comparacion con aquellos que no [mediana 4 (rango intercuartil (RIC) 4-9) versus 3 (RIC 2-5) dias; p = 0.04].Este estudio no utilizo la produccion de orina como una modalidad para detectar dano renal agudo. Los datos se limitan a una muestra de pacientes de un gran centro medico academico, que participa en el Programa Nacional de Mejora de la Calidad Quirurgica. Las intervenciones o programas implementados en nuestra institucion, destinados a la reduccion de infecciones u otras iniciativas, con el objetivo de mejorar la calidad, no se tomaron en cuenta para este estudio.La implementacion de una Recuperacion Mejorada despues del protocolo de cirugia, se asocia independientemente con el desarrollo de lesion renal aguda postoperatoria.Consulte Video Resumen en http://links.lww.com/DCR/B69. (Traduccion-Dr. Fidel Ruiz-Healy).

Wound complication following gastrointestinal surgery substantially impacts the quality and costs of surgical care. The impact of wound complication on subsequent long-term healthcare utilization has not been fully studied. We assessed the impact of surgical wound complication on inpatient and outpatient healthcare utilization in the 2 years after gastrointestinal (GI) surgery. An observational retrospective cohort study was conducted on Veterans Affairs health system patients who underwent an inpatient GI surgical procedure, were assessed by the Veterans Affairs Surgical Quality Improvement Program (VASQIP), and were discharged alive from Veterans Affairs (VA) hospitals between October 1, 2007 and September 30, 2014. Population-based A total of 64,351 patients underwent a GI surgical procedure in the VA system between 2007 and 2014. The cohort was 93.5% male, with a median age of 63.0 years (interquartile range (IQR) 57.0–70.0). A total of 7880 patients (12.2%) had at least one reported wound complication, 5460 of which had their postoperative wound complication classified by a VASQIP nurse. VASQIP-assessed or ICD-9-coded wound complication in the 30 days after surgery Inpatient visits, total inpatient days, outpatient visits, and emergency department visits, and operative interventions up to 2 years after discharge from index admission Patients with a postoperative wound complication had greater inpatient healthcare utilization compared with no-wound complication for up to 2 years after surgery: inpatient admissions (mean number 3.5 vs. 2.8; P

Patients with limited health literacy (HL) have difficulty understanding written/verbal information. The quality of verbal communication is not well understood. Therefore, our aim was to characterize patient-surgeon conversations and identify opportunities for improvement.New colorectal patient-surgeon encounters were audio-recorded and transcribed. HL was measured. Primary outcomes were rates-of-speech, understandability of words, patient-reported understanding, and usage of medical jargon/statistics. Secondary outcomes included length-of-visit (LOV), conversation possession time, patient-surgeon exchanges, and speech interruptions.Significant variations existed between surgeons in rates-of-speech and understandability of words (p 0.05). Faster rates-of-speech were associated with significantly less understandable words (p 0.05). Patient-reported understanding varied by HL and by surgeon. Conversation possession time and usage of medical jargon/statistics varied significantly by surgeon (p 0.05) in addition to patient-surgeon exchanges and interruptions. Patients with limited HL had shorter LOV.Significant variations exist in how surgeons talk to patients. Opportunities to improve verbal communication include slowing speech and using more understandable words.

Background The extent of preoperative opioid utilization and the relationship with pain-related readmissions are not well understood. Methods VA Surgical Quality Improvement Program data on general, vascular, and orthopedic surgeries (2007–2014) were merged with pharmacy data to evaluate preoperative opioid use and pain-related readmissions. Opioid use in the 6-month preoperative period was categorized as none, infrequent, frequent, and daily. Results In the six-month preoperative period, 65.7% had no opioid use, 16.7% had infrequent use, 6.3% frequent use, and 11.4% were daily opioid users. Adjusted odds of pain-related readmission were higher for opioid-exposed groups vs the opioid-naive group: infrequent (OR 1.17; 95% CI:1.04–1.31), frequent (OR 1.28; 95% CI:1.08–1.52), and daily (OR 1.49; 95% CI:1.27–1.74). Among preoperative opioid users, those with a pain-related readmission had higher daily preoperative oral morphine equivalents (mean 44.5 vs. 36.1, p Conclusions Patients using opioids preoperatively experienced higher rates of pain-related readmissions, which increased with frequency and dosage of opioid exposure.

BACKGROUND: This retrospective study compares a multidisciplinary clinic (MDC) to standard care for time to treatment of colorectal cancer. METHODS: We queried our institutional ACS-NSQIP database for patients undergoing surgery for colorectal cancer from 2017–2020. Patients were stratified by initial clinic visit (MDC vs control). Primary endpoint was the time to start treatment (TST), either neoadjuvant therapy or surgery, from the date of diagnosis by colonoscopy. RESULTS: A total of 405 patients were evaluated (115 MDC, 290 Control). TST from diagnosis was not significantly shorter for the MDC cohort (MDC 30 days, Control 37 days; p=0.07) even when stratified by type of initial treatment of neoadjuvant therapy (MDC 30, Control 34 days; p=0.28) or surgery (MDC 32.5 days, Control 38 days; p=0.35). CONCLUSION: Implementation of an MDC provides insignificant reduction in delay to start treatment for colorectal cancer patients as compared to standard care colorectal surgery clinics.

Background Health literacy is a determinant of health. Few studies characterize its association with surgical outcomes. Methods Retrospective cohort study of patients undergoing elective colorectal surgery 2015-2020. Health literacy assessed using Brief Health Literacy Screening Tool. Outcomes were postoperative complications, LOS, readmissions, mortality. Results Of 552 patients, 46 (8.3%) had limited health literacy, 506 (91.7%) non-limited. Median age 57.7 years, 305 (55.1%) patients were female, 148 (26.8%) were Black. Limited patients had higher rates of overall complications (43.5% vs. 24.3%, p = 0.004), especially surgical site infections (21.7% vs. 11.3%, p = 0.04). Limited patients had longer LOS (5 vs 3.5 days, p = 0.006). Readmissions and mortality did not differ. On multivariable analysis, limited health literacy was independently associated with increased risk of complications (OR 2.03, p = 0.046), not LOS (IRR 1.05, p = 0.67). Conclusion Limited health literacy is associated with increased likelihood of complications after colorectal surgery. Opportunities exist for health literate surgical care to improve outcomes for limited health literacy patients.

Challenging discharges can lead to prolonged hospital stays. We hypothesized that surgical patients discharged from Veterans Affairs hospitals on weekdays have longer hospital stays and greater excess length of stay.We identified inpatient general and vascular procedures at Veterans Affairs hospitals from 2007 to 2014. Expected length of stay was calculated using a stratified negative binomial model adjusted for patient/operative characteristics. Excess length of stay was defined as the difference between observed and expected length of stay.We identified 135,875 patients (80.4% weekday discharges, 19.6% weekend discharges). The average length of stay was 7.5 days. Patients with weekday discharges spent on average 2.5 more days in the hospital compared with patients discharged on weekends (8.0 vs. 5.5 days, P.001); 28.5% of patients with weekday discharges had an observed length of stay at least 1 day longer than expected, compared with 16.4% of patients with weekend discharges (P.001).Surgical patients are less frequently discharged from Veterans Affairs hospitals on the weekends than during the week, and this corresponds to an increased excess length of stay for patients ultimately discharged on weekdays. Exploring the opportunity to coordinate safe weekend discharges may improve efficiency of post-surgery hospital care and reduce healthcare costs.

Objective The aim of this study was to obtain feedback from key stakeholders and end users to identify program strengths and weaknesses to plan for wider dissemination and implementation of the Virtual Acute Care for Elders (Virtual ACE) program, a novel intervention that improves outcomes for older surgical patients. Background Virtual ACE was developed to deliver evidence-based geriatric care without requiring daily presence of a geriatrician. Previous work demonstrated that Virtual ACE increased mobility and decreased delirium rates for surgical patients. Methods We conducted semi-structured interviews with 30 key stakeholders (physicians, nurses, hospital leadership, nurse managers, information technology staff, and physical/occupational therapists) involved in the implementation and use of the program. Results Our stakeholders indicated that Virtual ACE was extremely empowering for bedside nurses. The program helped nurses identify older patients who were at risk for a difficult postoperative recovery. Virtual ACE also gave them skills to manage complex older patients and more effectively communicate their needs to surgeons and other providers. Nurse managers felt that Virtual ACE helped them allocate limited resources and plan their unit staffing assignments to better manage the needs of older patients. The main criticism was that the Virtual ACE Tracker that displayed patient status was difficult to interpret and could be improved by a better design interface. Stakeholders also felt that program training needed to be improved to accommodate staff turnover. Conclusions Although respondents identified areas for improvement, our stakeholders felt that Virtual ACE empowered them and provided effective tools to improve outcomes for older surgical patients.

Background: Low health literacy is common in general populations, but its prevalence in the inflammatory bowel disease (IBD) population is unclear. The objective of this study was to assess the prevalence of low health literacy in a diverse IBD population and to identify risk factors for low health literacy. Methods: Adult patients with IBD at a single institution from November 2017 to May 2018 were assessed for health literacy using the Newest Vital Sign (NVS). Demographic and socioeconomic data were also collected. Primary outcome was the prevalence of low health literacy. Secondary outcomes were length-of-stay (LOS) and 30-day readmissions after surgical encounters. Bivariate comparisons and multivariable regression were used for analyses. Results: Of 175 IBD patients, 59% were women, 23% were African Americans, 91% had Crohn disease, and mean age was 46 years (SD = 16.7). The overall prevalence of low health literacy was 24%. Compared to white IBD patients, African Americans had significantly higher prevalence of low health literacy (47.5% vs 17.0%, P < 0.05). On multivariable analysis, low health literacy was associated with older age and African American race (P < 0.05). Of 83 IBD patients undergoing abdominal surgery, mean postoperative LOS was 5.5 days and readmission rate was 28.9%. There was no significant difference between LOS and readmissions rates by health literacy levels. Conclusions: Low health literacy is present in IBD populations and more common among older African Americans. Opportunities exist for providing more health literacy-sensitive care in IBD to address disparities and to benefit those with low health literacy., Lay Summary Low health literacy exists in the inflammatory bowel disease (IBD) population. Older African Americans with IBD represent a subset at even higher risk for low health literacy. Opportunities exist for providing more health literacy-sensitive care in IBD to address disparities.

Background Enhanced Recovery Programs (ERPs) benefit patients but their effects on healthcare costs remain unclear. This study aimed to investigate the costs associated with a colorectal ERP in a large academic health system. Methods Patients who underwent colorectal surgery from 2012 to 2014 (pre-ERP) and 2015–2017 (ERP) were propensity score matched based on patient and operative-level characteristics. Primary outcomes were median variable, fixed, and total costs. Secondary outcomes included length-of-stay (LOS), readmissions, and postoperative complications (POCs). Results 616 surgical cases were included. Patient and operative-level characteristics were similar between the cohorts. Variable costs were $1028 less with ERP. ERP showed savings in nursing, surgery, anesthesiology, pharmacy, and laboratory costs, but had higher fixed costs. Total costs between the two groups were similar. ERP patients had significantly shorter LOS (−1 day, p Conclusions Implementation of an ERP for colorectal surgery was associated with lower variable costs compared to pre-ERP.

The prevalence of anal disease in oncology patients is reportedly 2–32%, with mortality rates ranging from 11–57% secondary to complications from perianal sepsis. Neutropenic patients lack the appropriate immune response necessary to overcome anorectal infections, making these infections significant and potentially lethal. Treatment of anorectal disease in the neutropenic patient population is challenging. The optimal management has historically been debated. Recently, operative intervention has become discouraged for this patient population as a result of the improved outcomes with supportive care. However, for certain patients within this population an operation may be appropriate and lifesaving.

Developing a successful academic colorectal surgery practice involves collaboration with other physicians and surgeons, participating in educational conferences, establishing expertise, championing clinical care pathways, and leading quality improvement.

The aim of this study is to examine the relationship between the sex pay gap in a large academic department of surgery and a recently instituted structured compensation plan.A recent large study found that after controlling for measures of academic and clinical productivity, male physicians earned nearly $20,000 more annually than female physicians. Increased salary transparency has been proposed as a method to reduce this disparity.A new structured compensation plan was developed to improve transparency of compensation and financial viability of each division. The total compensations of each faculty member before and after the new compensation plan were calculated. Salaries were compared with the Association of Academic Medical Colleges (AAMC) median value based on specialty, region, academic rank, stratified by sex and compared. Work relative value units (wRVUs) were calculated for each faculty member during the entire study period, stratified by sex and compared.Among 44 eligible surgeons (33 men and 11 women), a sex pay gap existed with male surgeon salaries significantly higher than female surgeon salaries [56% (8 to 213) vs 26% (1 to 64); P0.00001] despite similar RVU production (men 8725 ± 831 vs women 7818 ± 911, P = 0.454). The new compensation plan did not significantly change male surgeon salaries [56% (8 to 213) vs 58% (26 to 159); P = 0.552] but did significantly increase the salaries of female surgeons [26% (1 to 64) vs 42% (10 to 80); P = 0.026].A structured compensation plan can improve the sex pay gap in a short period of time. More transparency in surgical compensation plans is essential to understand the most equitable way to compensate all surgeons.

To evaluate whether burnout was associated with emotional intelligence and job performance in surgical residents.General surgery residents at a single institution were surveyed using the Maslach Burnout Inventory (MBI) and trait EI questionnaire (TEIQ-SF). Burnout was defined as scoring in 2 of the 3 following domains; Emotional Exhaustion (high), Depersonalization (high), and Personal Accomplishment (low). Job performance was evaluated using faculty evaluations of clinical competency-based surgical milestones and standardized test scores including the American Board of Surgery In-Training Exam (ABSITE) and the United States Medical Licensing Examination (USMLE) Step 3. USMLE Step 1 and USMLE Step 2, which were taken prior to residency training, were included to examine possible associations of burnout with USMLE examinations. Statistical comparison was made using Pearson correlation and simple linear regression adjusting for PGY level.This study was conducted at the University of Alabama at Birmingham (UAB) general surgery residency program.All current and incoming general surgery residents at UAB were invited to participate in this study.Forty residents participated in the survey (response rate 77%). Ten residents, evenly distributed from incoming residents to PGY-4, had burnout (25%). Mean global EI was lower in residents with burnout versus those without burnout (3.71 vs 3.9, p = 0.02). Of the 4 facets of EI, mean self-control values were lower in residents with burnout versus those without burnout (3.3 vs 4.06, p0.01). Each component of burnout was associated with global EI, with the strongest correlation being with personal accomplishment (r = 0.64; p0.01). Residents with burnout did not have significantly different mean scores for USMLE Step 1 (229 vs 237, p = 0.12), Step 2 (248 vs 251, p = 0.56), Step 3 (223 vs 222, p = 0.97), or ABSITE percentile (44.6 vs 58, p = 0.33) compared to residents without burnout. Personal accomplishment was associated with ABSITE percentile scores (r = 0.35; p = 0.049). None of the 16 surgical milestone scores were significantly associated with burnout.Burnout is present in surgery residents and associated with emotional intelligence. There was no association of burnout with USMLE scores, ABSITE percentile, or surgical milestones. Traditional methods of assessing resident performance may not be capturing burnout and strategies to reduce burnout should consider targeting emotional intelligence.

Acute kidney injury is associated with increased postoperative length of hospital stay and increases the risk of postoperative mortality. The association between the development of postoperative acute kidney injury and the implementation of an enhanced recovery after surgery protocol remains unclear.This study aimed to examine the relationship between the implementation of an enhanced recovery pathway and the development of postoperative acute kidney injury.In this retrospective cohort study, a prospectively maintained database of patients who underwent elective colorectal surgery in an enhanced recovery pathway were compared to a hospital historical National Surgical Quality Improvement Program colorectal registry of patients.This study was conducted at the University of Alabama at Birmingham, a tertiary referral center.A total of 1052 patients undergoing elective colorectal surgery from 2012 through 2016 were included.The development of postoperative acute kidney injury was the primary outcome measured.Patients undergoing an enhanced recovery pathway had significantly greater rates of postoperative acute kidney injury than patients not undergoing an enhanced recovery pathway (13.64% vs 7.08%; p0.01). Our adjusted model indicated that patients who underwent an enhanced recovery pathway (OR, 2.31; 95% CI, 1.48-3.59; p0.01) had an increased risk of acute kidney injury. Patients who developed acute kidney injury in the enhanced recovery cohort had a significantly longer median length of stay than those who did not (median 4 (interquartile range, 4-9) vs 3 (interquartile range, 2-5) days; p=0.04).This study did not utilize urine output as a modality for detecting acute kidney injury. Data are limited to a sample of patients from a large academic medical center participating in the National Surgical Quality Improvement Program. Interventions or programs in place at our institution that aimed at infection reduction or other initiatives with the goal of improving quality were not accounted for in this study.The implementation of an enhanced recovery after surgery protocol is independently associated with the development of postoperative acute kidney injury.See Video Abstract at http://links.lww.com/DCR/B69. LA ASOCIACIÓN DE VÍA DE RECUPERACIÓN MEJORADA Y LESIÓN RENAL AGUDA EN PACIENTES DE CIRUGÍA COLORRECTAL: La lesión renal aguda se asocia con una mayor duración en la estancia hospitalaria y aumenta el riesgo de la mortalidad postoperatoria. La asociación entre el desarrollo de la lesión renal aguda postoperatoria y la implementación de un protocolo de Recuperación Mejorada después de la cirugía, sigue sin ser clara.Examinar la relación entre la implementación de una vía de Recuperación Mejorada y el desarrollo de lesión renal aguda postoperatoria.Estudio de cohorte retrospectivo, de una base de datos mantenida prospectivamente, de pacientes que se sometieron a cirugía colorrectal electiva, en una vía de Recuperación Mejorada, se comparó con el registro histórico de los pacientes colorrectales del Programa Nacional de Mejora de la Calidad Quirúrgica.Universidad de Alabama en Birmingham, un centro de referencia terciario.Un total de 1052 pacientes sometidos a cirugía colorrectal electiva desde 2012 hasta 2016.Desarrollo de lesión renal aguda postoperatoria.Los pacientes sometidos a una vía de Recuperación Mejorada, tuvieron tasas significativamente mayores de lesiones renales agudas postoperatorias, en comparación con los pacientes de Recuperación no Mejorada (13.64% vs 7.08%; p0.01). Nuestro modelo ajustado indicó que los pacientes que se sometieron a una vía de Recuperación Mejorada (OR, 2.31; IC, 1.48-3.59; p0.01) tuvieron un mayor riesgo de lesión renal aguda. Los pacientes que desarrollaron daño renal agudo en la cohorte de Recuperación Mejorada, tuvieron una estadía mediana significativamente más larga en comparación con aquellos que no [mediana 4 (rango intercuartil (RIC) 4-9) versus 3 (RIC 2-5) días; p = 0.04].Este estudio no utilizó la producción de orina como una modalidad para detectar daño renal agudo. Los datos se limitan a una muestra de pacientes de un gran centro médico académico, que participa en el Programa Nacional de Mejora de la Calidad Quirúrgica. Las intervenciones o programas implementados en nuestra institución, destinados a la reducción de infecciones u otras iniciativas, con el objetivo de mejorar la calidad, no se tomaron en cuenta para este estudio.La implementación de una Recuperación Mejorada después del protocolo de cirugía, se asocia independientemente con el desarrollo de lesión renal aguda postoperatoria.Consulte Video Resumen en http://links.lww.com/DCR/B69. (Traducción-Dr. Fidel Ruiz-Healy).

Homeless Veterans are vulnerable to poor care transitions, yet little research has examined their risk of readmission following inpatient surgery. This study investigates the predictors of surgical readmission among homeless relative to housed Veteran patients.Inpatient general, vascular, and orthopedic surgeries occurring in the Veterans Health Administration from 2008 to 2014 were identified. Administrative International Classification of Diseases, Ninth Revision, Clinical Modification codes and Veterans Health Administration clinic stops were used to identify homeless patients. Bivariate analyses examined characteristics and predictors of readmission among homeless patients. Multivariate logistic models were used to estimate the association between homeless experience and housed patients with readmission following surgery.Our study included 232,373 surgeries: 43% orthopedic, 39% general, and 18% vascular with 5068 performed on homeless patients. Homeless individuals were younger (56 vs. 64 y, P0.01), more likely to have a psychiatric comorbidities (51.3% vs. 19.4%, P0.01) and less likely to have other medical comorbidities such as hypertension (57.1% vs. 70.8%, P0.01). Homeless individuals were more likely to be readmitted [odds ratio (OR), 1.43; confidence interval (CI), 1.30-1.56; P0.001]. Discharge destination other than community (OR, 0.57; CI, 0.44-0.74; P0.001), recent alcohol abuse (OR, 1.45; CI, 1.15-1.84; P0.01), and elevated American Society Anesthesiologists classification (OR, 1.86; CI, 1.30-2.68; P0.01) were significant risk factors associated with readmissions within the homeless cohort.Readmissions are higher in homeless individuals discharged to the community after surgery. Judicious use of postoperative nursing or residential rehabilitation programs may be effective in reducing readmission and improving care transitions among these vulnerable Veterans. Relative costs and benefits of alternatives to community discharge merit investigation.

Studies suggest Asian Americans may have improved oncologic outcomes compared with other ethnicities. We hypothesized that Asian Americans with colorectal cancer would have improved surgical outcomes in mortality, postoperative complications (POCs), length of stay (LOS), and readmissions compared with other racial/ethnic groups.We queried the 2011-2014 American College of Surgeons National Surgical Quality Improvement Program for patients who underwent surgery for colorectal cancer and stratified patients by race. Primary outcome was 30-d mortality with secondary outcomes including POCs, LOS, and 30-d readmission. Stepwise backward logistic regression analyses and incident rate ratio calculations were performed to identify risk factors for disparate outcomes.Of the 28,283 patients undergoing colorectal surgery for malignancy, racial/ethnic groups were divided into Caucasian American (84%), African American (12%), or Asian American (4%). On unadjusted analyses, compared with other racial/ethnic groups, Asian Americans were more likely to have normal weight, not smoke, and had lower American Society of Anesthesiologists score of 1 or 2 (P 0.001). Postoperatively, Asian Americans had the shortest LOS and the lowest rates of complications due to ileus, respiratory, and renal complications (P 0.001). There were no racial differences in 30-d mortality or readmission. On adjusted analyses, Asian American race was independently associated with less postoperative ileus (odds ratio 0.8, 95% confidence interval 0.66-0.98, P 0.001) and decreased LOS by 13% and 4% compared with African American and Caucasian American patients, respectively (P 0.001).Asian Americans undergoing surgery for colorectal cancer have shorter LOS and fewer POCs when compared with other racial/ethnic groups without differences in 30-d mortality or readmissions. The mechanism(s) underlying these disparities will require further study, but may be a result of patient, provider, and healthcare system differences.

OBJECTIVE: We hypothesized that inpatient postoperative pain trajectories are associated with 30-day inpatient readmission and emergency department (ED) visits. BACKGROUND: Surgical readmissions have few known modifiable predictors. Pain experienced by patients may reflect surgical complications and/or inadequate or difficult symptom management. METHODS: National Veterans Affairs Surgical Quality Improvement data on inpatient general, vascular, and orthopedic surgery from 2008 to 2014 were merged with laboratory, vital sign, health care utilization, and postoperative complications data. Six distinct postoperative inpatient patient-reported pain trajectories were identified: (1) persistently low, (2) mild, (3) moderate or (4) high trajectories, and (5) mild-to-low or (6) moderate-to-low trajectories based on postoperative pain scores. Regression models estimated the association between pain trajectories and postdischarge utilization while controlling for important patient and clinical variables. RESULTS: Our sample included 211,231 surgeries—45.4% orthopedics, 37.0% general, and 17.6% vascular. Overall, the 30-day unplanned readmission rate was 10.8%, and 30-day ED utilization rate was 14.2%. Patients in the high pain trajectories had the highest rates of postdischarge readmissions and ED visits (14.4% and 16.3%, respectively, P < 0.001). In multivariable models, compared with the persistently low pain trajectory, there was a dose-dependent increase in postdischarge ED visits and readmission for pain-related diagnoses, but not postdischarge complications (χ(2) trend P < 0.001). CONCLUSIONS: Postoperative pain trajectories identify populations at risk for 30-day readmissions and ED visits, and do not seem to be mediated by postdischarge complications. Addressing pain control expectations before discharge may help reduce surgical readmissions in high pain categories.

PURPOSE: Discontinuation of statin therapy represents a major challenge for effective cardiovascular disease prevention. It is unclear how often primary care physicians (PCPs) re-initiate statins and what barriers they encounter. We aimed to identify PCP perspectives on factors influencing statin re-initiation. METHODS: We conducted six nominal group discussions with 23 PCPs from the Deep South Continuing Medical Education network. PCPs answered questions about statin side effects, reasons their patients reported for discontinuing statins, how they respond when discontinuation is reported, and barriers they encounter in getting their patients to re-initiate statin therapy. Each group generated a list of responses in round-robin fashion. Then, each PCP independently ranked their top three responses to each question. For each PCP, the most important reason was given a weight of 3 votes, and the second and third most important reasons were given weights of 2 and 1, respectively. We categorized the individual responses into themes and determined the relative importance of each theme using a “percent of available votes” metric. RESULTS: PCPs reported that side effects, especially muscle/joint-related symptoms, were the most common reason patients reported for statin discontinuation (47% of available votes). PCPs reported statin re-challenge as their most common response when a patient discontinues statin use (31% of available votes). Patients’ fear of side effects was ranked as the biggest challenge PCPs encounter in getting their patients to re-initiate statin therapy (70% of available votes). CONCLUSION: PCPs face challenges getting their patients to re-initiate statins, particularly after a patient reports side effects.

Background We evaluated postoperative venous thromboembolism (VTE) chemical prophylaxis adherence to assess the preventability of VTEs. Methods A case-control study was performed using the 2011–2015 ACS-NSQIP single institution database. Cases were identified as patients who experienced postoperative VTE within 30 days following surgery. Controls were matched 2:1 on procedure, age, and BMI. Association between inpatient chemical prophylaxis adherence and postoperative VTE was evaluated with conditional logistic regression. Results Seventy-three cases were matched to 145 controls. Complete inpatient VTE chemical prophylaxis adherence did not differ between cases and controls (45.2% vs. 46.2%, p = 1.00). Odds of postoperative VTE increased if a patient's prophylaxis was interrupted (OR 6.34, 95% CI 1.82–22.13). However, 53.7% of instances of interrupted prophylaxis were medically justified by concern for bleeding, spine operation, or for additional upcoming procedure. Conclusions Nearly half of patients who experienced postoperative VTEs received appropriate guideline-driven care. Most interruptions in chemical prophylaxis were justified medically. This further questions the preventability of postoperative VTEs and the utility of this outcome as a valid measure of hospital quality.

Background Emotional intelligence (EI) has been associated with improved work performance and job satisfaction in several industries. We evaluated whether EI was associated with higher measures of work performance and job satisfaction in surgical residents. Methods We distributed the validated Trait EI Questionnaire and job satisfaction survey to all general surgery residents at a single institution in 2015. EI and job satisfaction scores were compared with resident performance using faculty evaluations of clinical competency–based surgical milestones and standardized test scores including the United States Medical Licensing Examination (USMLE) and American Board of Surgery In-Training Examination (ABSITE). Statistical comparison was made using Pearson correlation and simple linear regression adjusting for postgraduate year level. Results The survey response rate was 68.9% with 31 resident participants. Global EI was associated with scores on USMLE Step 2 (r = 0.46, P = 0.01) and Step 3 (r = 0.54, P = 0.01) but not ABSITE percentile scores (r = 0.06, P = 0.77). None of the 16 surgical milestone scores were significantly associated with global EI or EI factors before or after adjustment for postgraduate level. Global EI was associated with overall job satisfaction (r = 0.37, P = 0.04). Of the facets of job satisfaction, global EI was significantly associated with views of supervision (r = 0.42, P = 0.02) and nature of work (r = 0.41, P = 0.02). Conclusions EI was associated with job satisfaction and USMLE performance but not ACGME competency–based milestones or ABSITE scores. EI may be an important factor for fulfillment in surgical training that is not currently captured with traditional in-training performance measures.

Mesh repair offers advantages like lower postsurgical pain and earlier return to work. Thus, it has become a widely used treatment option. Here, we present the first case report of a mesh migration into a J-pouch in a patient with history of ulcerative colitis who underwent total abdominal colectomy with J-pouch and ileoanal anastomosis and a subsequent laparoscopic ventral hernia repair with mesh.

Background Patient-reported outcomes (PROs) aid in rheumatoid arthritis (RA) management, but it is not well understood which measures would be most relevant to the rheumatologists for making treatment decisions. Methods We recruited rheumatologists nationally to participate in moderated structured group teleconference discussions using the nominal group technique. Participants in each group generated lists of the elements from patient’s history and signs that they use to make treatment recommendations for RA. Each participant then selected the three most important elements from the generated list. The results of each group were then combined and summarized. Results Twenty-five rheumatologists participated in 4 groups (group size ranged from 4 to 8) and 150 available ranking votes across all groups. The statements generated across the 4 groups were categorized into 13 topics (including symptoms, physical function, comorbidities, social aspects, physical findings, response to treatment, treatment adherence, pain management, side effects, tests, access to care, contraception, and organ involvement), 10 of which received ranking votes. Symptoms received the highest ranking (46% of votes), followed by physical function (16%), and physical findings (13%). Among the unranked topics, social aspects had the highest number of statements (8 statements). Conclusion Rheumatologists highly valued patient-reported RA symptoms and physical function to inform their treatment decisions, even above objective data such as physical findings and test results. These results can guide the selection of validated PRO measures to assess these domains to inform the clinical care of patients with rheumatoid arthritis. Electronic supplementary material The online version of this article (10.1186/s41927-019-0087-2) contains supplementary material, which is available to authorized users.

Wound complication following gastrointestinal surgery substantially impacts the quality and costs of surgical care. The impact of wound complication on subsequent long-term healthcare utilization has not been fully studied.We assessed the impact of surgical wound complication on inpatient and outpatient healthcare utilization in the 2 years after gastrointestinal (GI) surgery.An observational retrospective cohort study was conducted on Veterans Affairs health system patients who underwent an inpatient GI surgical procedure, were assessed by the Veterans Affairs Surgical Quality Improvement Program (VASQIP), and were discharged alive from Veterans Affairs (VA) hospitals between October 1, 2007 and September 30, 2014.Population-based PARTICIPANTS: A total of 64,351 patients underwent a GI surgical procedure in the VA system between 2007 and 2014. The cohort was 93.5% male, with a median age of 63.0 years (interquartile range (IQR) 57.0-70.0). A total of 7880 patients (12.2%) had at least one reported wound complication, 5460 of which had their postoperative wound complication classified by a VASQIP nurse.VASQIP-assessed or ICD-9-coded wound complication in the 30 days after surgery MAIN OUTCOME MEASUREMENTS: Inpatient visits, total inpatient days, outpatient visits, and emergency department visits, and operative interventions up to 2 years after discharge from index admission RESULTS: Patients with a postoperative wound complication had greater inpatient healthcare utilization compared with no-wound complication for up to 2 years after surgery: inpatient admissions (mean number 3.5 vs. 2.8; P .001), inpatient bed days (mean 41.0 vs. 25.0; P .001). Patients with a postoperative wound complication also had greater 2-year outpatient utilization than the no-wound complication cohort: outpatient visits (mean number 92.7 vs. 75.9; P .001) and emergency department visits (mean 3.5 vs. 2.7; P .001). The same relationship held for wound-related parameters; inpatient admissions (2.2 vs. 0.4; P .001); inpatient bed days (21.4 vs. 3.7; P .001); and outpatient visits (56.2 vs. 9.7; P .001). A greater proportion of patients in the wound complication cohort had an operative intervention for all time intervals examined (P .001).Surgical wound complications impact healthcare utilization patterns for up to 2 years after the index procedure including hospital readmissions and operative interventions; efforts to reduce postoperative wound complications will have substantial effects on patient outcomes and healthcare expenditures well beyond the 30-day postoperative period.

Background Screening of hyperlipidemia in rheumatoid arthritis (RA) is suboptimal, despite RA patients’ high risk for cardiovascular disease (CVD) mortality. Objectives To identify barriers to screening for hyperlipidemia among patients with RA from the viewpoint of primary care physicians (PCPs) and rheumatologists. Methods We recruited rheumatologists and PCPs nationally to participate in separate moderated structured group teleconference discussions using the nominal group technique. Participants in each group generated lists of barriers to screening for hyperlipidemia in patients with RA, then each selected the three most important barriers from this list. Results Twenty-six rheumatologists participated in 3 groups and 20 PCPs participated in groups. The resulting barriers were organized into physician-, patient- and system-level barriers. Rheumatologists prioritized physician level barriers (e.g. ‘ownership’ of hyperlipidemia screening), whereas PCPs prioritized patient-level barriers (e.g. complexity of RA itself). See table 1 for details. Conclusion These rheumatologists were conflicted about whether screening of CVD risk among patients with RA should fall within the role of the rheumatologist or PCPs. On the other hand, participating PCPs were concerned about the overall effect of RA and RA treatments in the context of screening hyperlipidemia. Note: RA = rheumatoid arthritis; CVD = cardiovascular disease; 0% = that sub-theme emerged during the brainstorming session but did not receive votes; “ – “ = the sub-theme did not emerge in the respective group. Disclosure of Interests Iris Navarro-Millan: None declared, Anna Cornelius-Schecter: None declared, Ronan O’Beirne Grant/research support from: Pfizer, Inc., Melanie Morris: None declared, Geyanne Lui: None declared, Susan Goodman Grant/research support from: Novartis: research support, Consultant for: Novartis, UCB, Pfizer: consulting, Andrea Cherrington: None declared, Liana Fraenkel: None declared

IMPORTANCE: Proteinuria indicates renal dysfunction and is a risk factor for morbidity among medical patients, but less is understood among surgical populations. There is a paucity of studies investigating how preoperative proteinuria is associated with surgical outcomes, including postoperative acute kidney injury (AKI) and readmission. OBJECTIVE: To assess preoperative urine protein levels as a biomarker for adverse surgical outcomes. DESIGN, SETTING, AND PARTICIPANTS: A retrospective, population-based study was conducted in a cohort of patients with and without known preoperative renal dysfunction undergoing elective inpatient surgery performed at 119 Veterans Affairs facilities from October 1, 2007, to September 30, 2014. Data analysis was conducted from April 4 to December 1, 2016. Preoperative dialysis, septic, cardiac, ophthalmology, transplantation, and urologic cases were excluded. EXPOSURES: Preoperative proteinuria as assessed by urinalysis using the closest value within 6 months of surgery: negative (0 mg/dL), trace (15-29 mg/dL), 1+ (30-100 mg/dL), 2+ (101-300 mg/dL), 3+ (301-1000 mg/dL), and 4+ (>1000 mg/dL). MAIN OUTCOMES AND MEASURES: Primary outcome was postoperative predischarge AKI and 30-day postdischarge unplanned readmission. Secondary outcomes included any 30-day postoperative outcome. RESULTS: Of 346 676 surgeries, 153 767 met inclusion criteria, with the majority including orthopedic (37%), general (29%), and vascular procedures (14%). Evidence of proteinuria was shown in 43.8% of the population (trace: 20.6%, 1+: 16.0%, 2+: 5.5%, 3+: 1.6%) with 20.4%, 14.9%, 4.3%, and 0.9%, respectively, of the patients having a normal preoperative estimated glomerular filtration rate (eGFR). In unadjusted analysis, preoperative proteinuria was significantly associated with postoperative AKI (negative: 8.6%, trace: 12%, 1+: 14.5%, 2+: 21.2%, 3+: 27.6%; P

Patient perceptions of the causes of preoperative symptoms, expected impact of surgery on symptoms and anticipated timeline of recovery are likely to affect the risk of readmission following elective surgical procedures. However, these perceptions have not been studied. A qualitative study was designed to explore these perceptions, using the common-sense model of self-regulation (CSM) as the conceptual framework. CSM is grounded in illness representations, describing how patients make sense of changes in physical well-being (e.g. symptoms) and develop and assess management plans. It also establishes a broader framework for examining patients' a priori expectations and timelines for outcomes based on comparisons to prior experiences and underlying self-prototypes, or "Self as Anchor". A convenience sample of 14 patients aged 56-81 who underwent elective surgery was recruited. Semi-structured interviews informed by the CSM were completed on the day of discharge. Content analysis with deductive coding was used, and emerging themes were fit to components of the CSM, including the five domains of Illness Representations-identity, cause, timeline, control, and consequences. Two additional themes, outlook (toward the health care system, providers and recovery efforts), and motivation (external or internal for recovering), relate to self-prototypes, expectations for outcomes, and search for coherence. Misattribution of symptoms, unrealistic expectations for outcomes (e.g. expecting complete resolution of symptoms unrelated to the surgical procedure) and timelines for recovery (unrealistically short), and the (baseline) "normal healthy self" as distinct from the (temporarily) "sick self" were recurrent themes. Findings suggest that patient perceptions and the actual recovery process may be misaligned. The results underscore the importance of assessing patients' perceptions and expectations, actively engaging patients in their own healthcare, and providing adequate support during the transition to home.

Postoperative education, discharge instructions, and follow-up appointments provide a foundation for new ostomates after discharge, but a gap in care remains. New ostomates utilize resources twice as much as other colorectal patients. Virtual visits allow visual inspection of the patient while providing verbal support. The purposes of this project were to determine the feasibility of Virtual Postoperative Visits, to define specific issues patients want addressed, and to assess patient satisfaction with a virtual format. In this pilot project, 10 patients attended two outpatient virtual visits following hospital discharge. The virtual visits were conducted using video conferencing software. Descriptive statistics were used to analyze data from a survey assessing patient satisfaction; content analysis described video interactions. All patients successfully completed two virtual visits from their homes. Ninety percent felt these visits helped with ostomy management and agreed they should be part of a discharge plan. All patients felt comfortable with a virtual format. Common themes discussed included pouching and skin irritation. We found that virtual visits are feasible, and patients are satisfied with this format to address goals of care. Future work will focus on large-scale implementation of virtual visits for new ostomates.

OBJECTIVE: To investigate the effects of enhanced recovery after surgery (ERAS) on racial disparities in postoperative length of stay (pLOS) after colorectal surgery. BACKGROUND: Racial disparities in surgical outcomes exist. We hypothesized that ERAS would reduce disparities in pLOS between black and white patients. METHODS: Patients undergoing ERAS in 2015 were 1:1 matched by race/ethnicity, age, sex, and procedure to a pre-ERAS group from 2010 to 2014. After stratification by race/ethnicity, expected pLOS was calculated using the American College of Surgeons National Surgical Quality Improvement Project Risk Calculator. Primary outcome was the observed pLOS and observed-to-expected difference in pLOS. Secondary outcomes were National Surgical Quality Improvement Project postoperative complications including 30-day readmissions and mortality. Adjusted sensitivity analyses on pLOS were also performed. RESULTS: Of 420 patients (210 ERAS and 210 pre-ERAS) examined, 28.3% were black. Black and white patients were similar in age, body mass index, sex, American Anesthesia Association class, and minimally invasive approaches. Within the pre-ERAS group, black patients stayed a mean of 2.7 days longer than expected compared with white patients (P < 0.05). Overall, ERAS patients had a significantly shorter pLOS (5.7 vs 8 days) and observed-to-expected difference (−0.7 vs 1.4 days) compared with pre-ERAS patients (P < 0.01). In the ERAS group, disparities in pLOS were reduced with no differences in readmissions or mortality between black and white patients. On sensitivity analyses, race/ethnicity remained a significant predictor of pLOS among pre-ERAS patients, but not for ERAS patients. CONCLUSIONS: ERAS eliminated racial differences in pLOS between black and white patients undergoing colorectal surgery. Reduced pLOS occurred without increases in mortality, readmissions, and most postoperative complications. ERAS may provide a practical approach to reducing disparities in surgical outcomes.

Introduction One of the most common late complications following stoma construction is prolapse. Although the majority of prolapse can be managed conservatively, surgical revision is required with incarceration/strangulation and in certain cases laparotomy and/or stoma reversal are not appropriate. This report will inform surgeons on safe and effective approaches to revising prolapsed stomas using local techniques. Presentation of case A 58 year old female with an obstructing rectal cancer previously received a diverting transverse loop colostomy. On completion of neoadjuvant treatment, re-staging found new lung metastases. She was scheduled for further chemotherapy but incarcerated a prolapsed segment of her loop colostomy. As there was no plan to resect her primary rectal tumor at the time, a local revision was preferred. Linear staplers were applied to the prolapsed stoma in step-wise fashion to locally revise the incarcerated prolapse. Post-operative recovery was satisfactory with no complications or recurrence of prolapse. Discussion We detail in step-wise fashion a technique using linear stapler devices that can be used to locally revise prolapsed stoma segments and therefore avoid a laparotomy. The procedure is technically easy to perform with satisfactory post-operative outcomes. We additionally review all previous reports of local repairs and show the evolution of local prolapse repair to the currently reported technique. Conclusion This report offers surgeons an alternative, efficient and effective option for addressing the complications of stoma prolapse. While future studies are needed to assess long-term outcomes, in the short-term, our report confirms the safety and effectiveness of this local technique., Highlights • Local repair of stoma prolapse avoids the consequences of a major laparotomy. • Step-wise application of linear staplers effectively repairs prolapsed stomas. • Patient outcomes are satisfactory after local repairs.